CPLP-sellaff Rev 12/13 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6210 Email: liquor.control@ct.gov Web Site: www.ct.gov/dcp/liquorcontrol AFFIDAVIT OF SELLER UNPAID OBLIGATIONS THIS FORM IS TO BE EXECUTED BY THE SELLER The undersigned permittee, backer or authorized representative of the backer: Name: (Last, First, Middle) Address: (Street Address & Number) State: Zip code: Representing: Name of Backer: BEING DULY SWORN DEPOSES AND SAYS: I AM OVER EIGHTEEN YEARS OF AGE AND BELIEVE IN THE OBLIGATION OF AN OATH. I AM THE BACKER, OR DULY AUTHORIZED REPRESENTATIVE OF THE BACKER, FOR THE PERMITTED LIQUOR PREMISES OPERATING UNDER THE BUSINESS NAME: Name of Permitted Liquor Business: Address: (Street Address & Number) State: Zip code: Operating with CT liquor permit number: Liquor Permit Number: Pursuant to 30-48(c) of the Connecticut General Statutes, I attest that: ALL OUTSTANDING OBLIGATIONS FOR THE PURCHASE OF ALCOHOLIC LIQUOR AT SUCH PERMIT PREMISES HAVE BEEN PAID. I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature of permittee, backer or authorized representative of the backer: X ________________________________________________________________ Date: __________________________ Subscribed and affirmed before me: Signed X__________________________________________________________ Date __________________________ (Commissioner of Superior Court, Notary Public, Justice of Peace) American LegalNet, Inc. www.FormsWorkFlow.com